Health inspection·August 15, 2024

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up and ensure all required documents were sent to the General Acute Care Hospital (GACH) Rehabilitation (Rehab) Center for evaluation, to address one of three sampled residents (Resident 1), requested transfer. Residents Affected - Few This deficient practice resulted to the delay in transfer and physical therapies in a GACH Rehab and had the potential to affect in maintaining Resident 1 ' s highest practicable physical, mental, and psychosocial well-being. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis (weakness or paralysis on one side of the body), muscle weakness (loss of muscle strength), and difficulty in walking (gait disorders). During a review of Resident 1 ' s History and Physical (H&P), the H&P dated 1/15/2024, indicated Resident 1 did not have the mental capacity to understand and make medical decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), the MDS dated [DATE], indicated Resident 1 ' s cognitive skills (thought process) was usually understood and understand by others. The MDS indicated Resident 1 was dependent with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 1 ' s GACH Rehab Center Case Management forms dated 5/24/2024, the form indicated Resident 1 ' s information was reviewed and noted. The form indicated Resident 1 ' s referral was incomplete and was unable to evaluate patient ' s functioning and ADLs. The notes indicated GACH Rehab Case Management called the facility but was unable to speak with the Social Services (SS). The notes indicated GACH Rehab spoke to a Charge Nurse (unidentified) and was informed Resident 1 ' s documentation sent were incomplete. The notes indicated Resident 1 ' s case would be closed at that time (5/24/2024). During a review of Resident 1 ' s SS progress notes dated 6/4/2024, the SS progress notes indicated SS sent a referral packet to GACH Rehab on 5/23/2024 after Resident 1 ' s family requested assistance to transfer Resident 1 to a GACH Rehab. The SS progress notes indicated the GACH Rehab Admissions Director did not accept Resident 1 (no reason indicated). Page 1 of 2 555348 555348 08/15/2024 Granada Post Acute 3565 E Imperial Hwy Lynwood, CA 90262

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/15/2024 at 12:46 p.m., with the SS, the SS stated on 5/23/2024, she (SS) faxed Resident 1 ' s referral papers to GACH Rehab. The SS stated the Admissions Director (AD) at GACH Rehab called the SS requesting Physical Therapy (PT) notes. The SS stated she faxed the PT notes but could not provide fax confirmation and documentation when PT notes were faxed to GACH Rehab. During an interview on 8/15/2024 at 1:36 p.m., with the AD at GACH Rehab, the AD stated the GACH Rehab received Resident 1 ' s referral on 5/24/24 at 4:30 p.m., but the referral was incomplete. The AD stated Resident 1 ' s case was closed because of the missing documents that were never received. The AD stated on 6/4/2024 at 4:45 p.m., we received documents but were incomplete. The AD stated the nurse (unidentified) called the SS to request more information, however, there were no documents received that day. The AD stated on 6/11/2024, the nurse at GACH Rehab could not determine if Resident 1 met the criteria for admission to the GACH Rehab due to missing PT notes. The AD stated Resident 1 was not accepted to the GACH Rehab because of the bed availability but because of the missing PT documents. During an interview on 8/15/2024 at 2:10 p.m., with the SS, the SS stated it was important for her to follow up and send the required documents to the GACH Rehab so Resident 1 will be evaluated and admitted to GACH Rehab. The SS stated Resident 1 could have benefited the intensive therapy GACH Rehab can provide. During a review of the facility ' s policy and procedure (P&P) titled, Discharge Planning Process, dated 10/2017, the P&P indicated the facility will document an evaluation of the resident ' s discharge needs and discharge plan based on the resident ' s needs. The P&P indicated all relevant resident information should be incorporated into the resident ' s discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident ' s transfer. 555348 Page 2 of 2